«Conceptual foundations of the treatment of psychosis The psychoanalytic treatment of the psychoses is founded on Sigmund Freud’s conceptual theses ...»
creation of the
world in the
Leonardo S. Rodriguez, PhD
Conceptual foundations of the treatment
The psychoanalytic treatment of the psychoses is founded on Sigmund Freud’s conceptual theses
concerning the psychotic process as clinically manifest in paranoic psychosis and schizophrenia.
Theoretical elaborations and clinical practice with other forms of psychosis, including manicdepressive psychosis, melancholia and autistic states require supplementary theoretical and practical considerations which go beyond the limits of this paper, even if most of the principles applicable to cases of paranoia and schizophrenia are still pertinent in those other clinical forms.
In addition, the conceptual map that I follow when working with psychotics incorporates the contributions of other psychoanalysts: Melanie Klein and her school, D.W. Winnicott and most especially Jacques Lacan. It was Lacan who took up the challenge posed by the psychoses at the point where Freud left some open questions—in particular, the question of a specific mechanism responsible for the formation of the symptoms that are pathognomonic of this clinical structure, namely, delusions and verbal hallucinations.
1 AJP 24 1 | LeonardoRodriguez_Destructionand.pdf Freud was not conclusive in his own formulations in this respect. Although he recognized that the mechanism of the unconscious responsible for the construction of symptoms in the neuroses, thatis, repression (Verdrängung), is not the dominant mechanism in psychotic structures, in his attempts to elucidate the psychotic phenomena he vacillated between the mechanisms of projection (Projektion)—to which he attributed only a partial contribution in the etiology of paranoia—, disavowal (Verleugnung) and foreclosure (Verwerfung). He had also proposed that disavowal is the prevailing mechanism in perversions, the third clinical structure of the trio of diagnostic categories (neuroses, perversions and psychoses) that to this day guide those of us of Freudian and Lacanian persuasion in the difficult task of conversing with psychotics and attempting to help them to live with, and learn from, their usually tragic human—all too human—existence.
The term foreclosure was not used by James Strachey, the English translator of Freud. Strachey preferred the terms ‘repudiation’ and ‘rejection’. ‘Foreclosure’ translates the German Verwerfung via the French forclusion, a term proposed by Jacques Lacan to designate the mechanism of the unconscious that he identified as responsible for psychotic formations, in a formula that includes other terms: foreclosure of the Name-of-the-Father. The English word derives etymologically from the French one, and both coverapproximately the same semantic field; so that since the publication of the English translation of a selection of Lacan’s Écrits twenty-seven years ago (Lacan 1977) it has been adopted by that portion of the English-speaking world more or less familiar with the works of Lacan and Lacanian analysts.
The experience of the end of the world and creativity Freud distinguished two moments in the phase of onset of psychosis. They are highly instructive as to the structure and function of the observable clinical phenomena, and they provide clues for our strategic approach in treatment. The first moment is that of the subject’s experience that Freud calls ‘the end of the world’ (which is how the patient usually calls it, using the same or equivalent expressions). The second moment corresponds to the subject’s attempts at recovery, when the typical psychotic symptoms (delusions and hallucinations) emerge.
Freud describes this decisive phase of onset eloquently, and has the assistance of his beloved
Goethe to render his account poetic. In his study of the Memoirs of President Schreber he says:
… during [Schreber’s] illness the world had come to an end … A world-catastrophe of this kind is not infrequent during the agitated stage in other cases of paranoia. … The patient has withdrawn from the people in his environment and from the external world generally the libidinal cathexis which he has hitherto directed on to them. Thus everything has become indifferent and irrelevant to him, and has to be explained by means of a secondary rationalization … the end of the world is the projection of this internal catastrophe; his subjective world has come to an end since his withdrawal of his love from it.
After Faust has uttered the curses which free him from the world, the Chorus of Spirits
Woe! Woe! Thou hast it destroyed, The beautiful world, With powerful fist!
And the paranoic builds it again, not more splendid, it is true, but at least so that he can once more live in it. He builds it up by the work of his delusions. The delusional formation, which we take to be the pathological product, is in reality an attempt at recovery, a process of reconstruction. Such a reconstruction after the catastrophe is successful to a greater or lesser extent, but never wholly so; in Schreber’s words, there has been a ‘profound internal change’ in the world. But the human subject has recaptured a relation, and often a very intense one, to the people and things in the world, even though the relation is a hostile one now … [This process] happens silently; we receive no intelligence of it, but can only infer it from subsequent events. What forces itself so noisily upon our attention is the process of recovery, which undoes the work of repression and brings back the libido again on to the people it had abandoned. In paranoia this method is carried out by the method of projection. It was incorrect to say [as Freud had suggested previously] that the perception which was suppressed internally is projected outwards; the truth is rather, as we now see, that what was abolished internally returns from without.
(Freud 1911c, 69–71) Order and production With Freud, we consider the symptomatic formations of the psychoses as productions oi the subject and not as mere deficits. These productions are the manifestations of a positive order, which is still an order even if psychotic, and not simply expressions of a disorder. This order restores, albeit partially, the world that had been destroyed at the initial moment of the phase of onset. And it is precisely this order in its variations that allows us to positively diagnose psychosis, that is to say, to identify it against the other two major clinical structures, and to discriminate within it the different clinical forms (paranoia, schizophrenia, etc.).
This order is an order of discourse: the diagnosis of psychosis, to this day, is based on the analysis of the subject’s discourse, and nothing else. Perhaps one day the wishes of some neuroscientists will be fulfilled, and the diagnosis of psychosis will be obtained through a blood test, or equivalent procedure. But for the time being to recognize psychosis one has to listen to the patient, and listen rather carefully and with patience, since the patient may well take a while to entrust us with the words that reveal his/ her position in the world. This is also the case for children, even if children may express themselves through media which, although an integral part of language, such as dramatic play, may not be composed entirely of verbalizations.
Listening to the psychotic enables us to detect the processes always present in his discourse that 3 AJP 24 1 | LeonardoRodriguez_Destructionand.pdf affect the construction of messages or the status of the code, or both. Such processes have the effect of placing the psychotic ‘outside discourse’, as Lacan put it—outside ordinary discourse.
Common discourse creates social bonds founded on modalities of relation, or ‘primordial statements’ inscribed in language (Lacan, 1991; 1998). The psychotic is excluded from the social bond constituted in and by discourse. In paranoic psychosis, this exclusion leads to disarray in the relations with the world, with other humans, who become abusive persecutors. In schizophrenia this exclusion leads to disarray in the relations with the subject’s own body, that is, the representation of the body—as distinct from the biological unit of the organism—that loses its unity to become a fragmentary, uninhabitable habitat. In chronic psychoses which commence early in life, the end of the world is a permanent threat, rather than a single episodic experience. In fact, the stabilization provided by the delusional reconstruction of the world after a discrete onset or series of onsets is always precarious, and the menace of the destruction of the world, overt or latent, is always hanging around the subject. It is beyond the scope of this paper to discuss the Lacanian theory of the reasons for these disarrays, namely, the foreclosure of the Name-of-the-Father, which is the organizing signifier that inscribes within the subject the prohibition of incest—that is, a clear distinction between the generations and a clear definition of the relations that are prohibited,—his/her identity as a sexed subject and the very dimension of desire as supported by the symbolic order, which is not only a representational, but also an ethical order. (Lacan 1976–77; 1993; 2002) My reflections here, based on practice as well as the study of the different psychoanalytic theories, are more concerned with a rationale for the psychoanalytic treatment of psychosis, a rationale based on the possibilities offered by the psychotic process itself. Freud created psychoanalysis with the help of hysterics who, in a sense, co-authored with him the foundation of the psychoanalytic clinical method, the fundamental rule of psychoanalysis (called ‘of free association’). Hysterics wanted to know the truth, and that put Freud on the right track towards the unconscious. Similarly, the psychotic’s desperate need to reconstruct, to create a world, may serve as the guide and motor for analytic work.
Stabilization and suppletion The psychotic’s attempts at recovery through the production of delusions and hallucinations are as a rule only temporarily successful and result in an unstable psychical organization manifested, for instance, in states of agitation or autistic withdrawal correlative to the impending world catastrophe, as well as the collapse of particular symbolic and social functions. Those attempts reveal nevertheless a logic (and ‘logic’ originally comes from logos, ‘discourse’) which, being delusional, is only a semblance of the logic of common discourse. Yet it should not be dismissed as being crazy or nonsensical, since it may be possible to construct something out of it that is not psychotic. For many patients, those attempts are the driving force for activities which, although originally inspired by a delusional project, operate nevertheless as compensations whose realization transcends the plane of the delusional. These compensations must be creative in order to be successful; creative, in that they must serve the psychotic’s need to construct a body and a world where to live: a body and a world with a necessary minimum of stability, consistence and peace. We speak of suppletion (French suppléance) to designate this creative work of compensation: a substitution or ‘prosthetic device’ (as it has also been called) that replaces the destroyed world. It has to be the subject’s own creation; any attempt to impose a suppletion onto the subject is in all probability going to fail, as it would appear to him as coming from the world whose very existence is in question, and therefore fake. The subject’s own creation serves a function of discourse, a social function: it may constitute a symbolic and material bridge with other human beings, over and above its idiosyncratic subjective value.
4 AJP 24 1 | LeonardoRodriguez_Destructionand.pdf Writing is the name that best encompasses the psychotic’s efforts to remain in this world by creating a new one, the old one being destroyed or unbearable as a place to live. In the sense in which I am employing the word (which follows Lacan’s developments), writing includes writing proper, but also all those human activities in which signifying things (words or other objects) are materially inscribed in the real. A wide variety of occupations offer the possibility of writing according to this definition. Considering only the psychotics whom I have treated or whose treatment I have supervised, I can mention gardening, sewing, gastronomy, computing, electronics, mechanical engineering, as well as different forms of artistic work and scientific research. Taken in this sense, words and objects operate like letters, which in themselves are devoid of meaning but whose combination is required for the construction of meaning. Letters are material, durable inscriptions that have a tangible and transmissible quality, unlike the transient, ephemeral existence of oral verbalizations and other forms of experience that are not permanently registered.
Our therapeutic strategy, then, follows the example provided by the work of psychotic writers, artists, scientists and people in other spheres of life who have been able to create a stable world for themselves (and sometimes others) through writing or productions that are equivalent to writing in the sense defined above. Writing as a form of registration enables the psychotic to inscribe his/her experience in a way which is itself pacifying, non-destructive and nonpersecutory—inscribe it materially on surfaces that can be read and, unlike the delusion, shared with others.
Freud first characterized the unconscious, which is the subject’s symbolic reservoir, as a series of writings, or registrations (Niederschriften) (Freud 1950a). Lacan argues that the psychotic has an unconscious, but it does not work (a notion already present in Freud; Freud 1915e). It does not work as it does for the neurotic, pushing him/her to the production of symptomatic formations that represent a form of satisfaction. The work of writing enables the psychotic to revive the unconscious, opening it to the production of creative metaphor.
Metaphor, where a signifying term is substituted for another, has the effect of bringing a new reality into the world: it is the creative instrument par excellence. And this is what the construction of a suppletion essentially entails. This is not possible in every case, but cannot be excluded for any case. Clinical experience has demonstrated its efficacy for many psychotic patients in psychoanalytic treatment.